An Overivew of NBCE Exam Development
Candidates typically take NBCE exams before graduating from chiropractic college. Exam scores are made available to licensing authorities within and outside the United States. In the U.S., all 50 states either accept or require passing scores on NBCE exams Parts I, II, III, and IV for licensure.
The NBCE Exam Development at a Glance
Computer-Based Tests (CBT)
Part I, Part II, Part III, and PHT are computer-based exams – formerly known as ‘written.’ The CBT exam development process begins in the chiropractic college classrooms where the subject material taught eventually comprises our written, computer-based exams.
NBCE’s test plans for CBT exams are based on a composite of material being taught and reflect the curricula at chiropractic colleges throughout the United States. Individual test questions – we call them items – that assess knowledge of specific subject material are submitted by chiropractic college faculty, test committee members, and chiropractic consultants. These items are reviewed by content specialists in a structured Test Development Committee for accuracy, and to ensure they are referenced in textbooks currently used in chiropractic colleges. Items are then categorized by subject, rewritten for clarity and to conform to the NBCE testing format. Then, the items are securely stored for use in upcoming exams.
To be included in an exam, each item must assess core knowledge that is taught at the majority of colleges and be referenced from our published list of textbooks commonly used in Doctor of Chiropractic curriculum. This long and complex process is completed to ensure state licensing boards, examinees, practicing Doctors of Chiropractic, and the general public that NBCE exams have been proven to accurately assess examinees’ understanding of the material being taught in school, thereby ensuring the safe and effective practice of chiropractic upon passing exams and eventually, license to practice.
This method of using structured communication and interactive forecasting techniques that rely on a panel of experts is referred to as the Delphi Method, and has been firmly established to prove that decisions from a structured group of experts are more accurate than those from unstrcutured groups.
The Delphi method is a structured, iterative process that gathers and refines expert input through multiple rounds of feedback to establish consensus on the knowledge, skills, and competencies required for professional practice and examination development.
The Delphi Method
Decades of peer-reviewed research support its use as an established methodology, with extensive study of its rigor, reliability, and application in healthcare education and assessment.
Academic & Research Sources:
The Practice Analysis of Chiropractic
The NBCE Practice Analysis of Chiropractic is a systematic, research-based study identifying the knowledge, skills, and abilities essential for safe and effective chiropractic practice. Using data collected from practicing chiropractors and expert analysis, its findings guide the development of the Part IV exam blueprint, ensuring exam content reflects current professional responsibilities.
Grounded in established scientific methods and rigorous data analysis, the practice analysis provides an evidence-based foundation for developing a fair, valid, and reliable examination for chiropractic licensure.
The Part IV Practical Exam
NBCE develops the Part IV examination through a rigorous, research-based process designed to assess the clinical skills and competencies required for safe and effective chiropractic practice. The process begins with a practice analysis, which examines the work chiropractors perform and identifies the knowledge, skills, and abilities essential to entry-level practice. Findings from the practice analysis inform the exam blueprint, ensuring the examination reflects the profession’s current scope of practice and the competencies most relevant to patient safety. The Practic Analysis of Chiropractic is conducted by the NBCE approximately every five years; the first conducted in 1991 (results published in 1993) and the most recent in 2024 (results published in 2025).
Subject-matter experts contribute to exam development by writing and reviewing assessment items aligned with the established blueprint. These items undergo review to ensure accuracy, relevance, clarity, and consistency with examination standards. Psychometric methods are used to evaluate exam performance and support the reliability and validity of score interpretations. Through ongoing research, expert review, and systematic evaluation, NBCE works to ensure the Part IV examination provides a fair, standardized assessment of the clinical skills required for chiropractic licensure.
How NBCE Uses Test Development Committees
Test Development Committees (TDCs) convene annually in Greeley, Colorado to review and approve items for upcoming written, computer-based exams: Part I, Part II, Part III, and PHT.
Each TDC is composed of experts in their field of study who teach the subject matter in chiropractic college—or in the case of Part III, are actively practicing members of their state chiropractic regulatory board.
After the submission of items (described above), TDC members review each item’s wording and its statistics to ensure the consistent quality and reliability of the NBCE exam process. After discussion, they perform the review and selection process for determining which items will appear on exam on which they are developing. This process from start to finish lasts almost two full days.
The NBCE Test Development Committees bring together subject matter experts to select the questions, or items, used on all of its exams. Participants include chiropractic college faculty nominated by Deans with final selection by NBCE, and practitioners from state boards serve on these annual Test Development Committees.
Standard Setting Committees are usually held every three years. Participants determine and approve the cut scores (passing) for exams. Members include chiropractic college faculty, practioners and state board members.
To ensure the fairness of all of its exams, the NBCE seeks committee members from every chiropractic college in the U.S. and from each state licensing board on a rotating basis.
Item Writing
Item writing is the development of exam questions (‘items’) that align with NBCE test blueprints and assess the knowledge, skills, and competencies required for safe and effective chiropractic practice. It is one step in the broader exam development process that includes practice analysis, test blueprint development, item review, psychometric evaluation, and ongoing examination maintenance.
Review Item Writing Guidelines here. (PDF)
History of NBCE Exam Development
The first NBCE tests consisted of what we still call the Part I and Part II Exams:
- Part I tests students in general and spinal anatomy, physiology, chemistry, pathology and microbiology.
- Part II assesses knowledge of general diagnosis, neuromusculoskeletal diagnosis, diagnostic imaging, principles of chiropractic, chiropractic practice and associated clinical sciences.
- Part III tests the applicant’s understanding of case history, physical examination, neuromusculoskeletal examination, diagnostic imaging, clinical laboratory and special studies, diagnosis or clinical impression, chiropractic techniques, supportive interventions and case management. This exam was added in 1987.
Then in 1995, the Part IV practical exam rounded out today’s four-part process. It tests hands-on skills. When a patient walks into the exam room, how does the chiropractor-to-be take the patient’s history and conduct the physical exam? Depending on symptoms, which tests should be ordered? Can the examinee properly read imaging? Can they demonstrate proper adjustment techniques? Administrating this exam involves developing case scenarios, training groups of patient actors and ensuring reproducible scoring methods.
ENSURING PROFESSIONAL COMPETENCY
and public safety through excellence in testing